The Joint Learning Network for Universal Health Coverage systematically documents the reforms of its member countries and other countries that have expanded health coverage through demand-side financing. The case studies contained in these pages are brief, comparative and modular in nature, describing the key highlights and technical features of each program.
Compare various dimensions of country reform efforts using our interactive tool.
| Program | Service delivery system | Public providers | Non-state providers | Service delivery system |
|---|---|---|---|---|
| Estonia: Estonian Health Insurance Fund |
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Health care provision in Estonia is completely decentralized. Care within the Estonian system is characterized by four tiers:
Health care provision in Estonia is completely decentralized. Care within the Estonian system is characterized by four tiers:
All health care providers operate as private, independent, legal entities. These entities can be private individuals, limited liability companies, or foundations. Most hospitals belong to local governments. They are managed as either limited companies or as non-profit foundations. Hospitals function as true business entities, with managers able to strive for better clinical practice and empowered to achieve improved financial performance. Management structures are explicit with a supervisory board and a management board governing the process. Maximum waiting times for specialized services vary by type. Ambulatory care is capped at four weeks, inpatient care and day surgeries are capped at eight months, and other interventions such as joint replacements have maximum waiting times of up to two and a half years. This initially led some patients to jump the queue by seeking care privately. However, queue jumping rules have recently been established to prevent private patients from getting quicker access to treatment. Cutting in the queue is only permitted in cases where the waiting list is caused by a provider having reached the EHIF contract volume. Service delivery must take place within agreed time limits. Emergency care must be provided immediately, outpatient specialist care must be provided within four weeks, and inpatient care must be provided within six months. Estonian Health Insurance FundService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: Health care provision in Estonia is completely decentralized. Care within the Estonian system is characterized by four tiers:
All health care providers operate as private, independent, legal entities. These entities can be private individuals, limited liability companies, or foundations. Most hospitals belong to local governments. They are managed as either limited companies or as non-profit foundations. Hospitals function as true business entities, with managers able to strive for better clinical practice and empowered to achieve improved financial performance. Management structures are explicit with a supervisory board and a management board governing the process. Maximum waiting times for specialized services vary by type. Ambulatory care is capped at four weeks, inpatient care and day surgeries are capped at eight months, and other interventions such as joint replacements have maximum waiting times of up to two and a half years. This initially led some patients to jump the queue by seeking care privately. However, queue jumping rules have recently been established to prevent private patients from getting quicker access to treatment. Cutting in the queue is only permitted in cases where the waiting list is caused by a provider having reached the EHIF contract volume. Service delivery must take place within agreed time limits. Emergency care must be provided immediately, outpatient specialist care must be provided within four weeks, and inpatient care must be provided within six months. |
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| Mali: Mutuelles |
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The provision of care in Mali is organized in a pyramid with four levels. At the base there are the health districts (60), divided into health areas that have a community health center (CSCOM) with a dispensary, a maternity center, and a pharmacy warehouse, altogether offering a minimum package of activities (MPA). The professional team at the CSCOM is often managed by a nurse. In 2010, about 900 of the 1,030 health areas had a CSCOM. The health area, and thus the CSCOM, is run by a community health association (ASACO). There were 954 ASACOs in 2010. The ASACO signs a contract with the government of Mali, which agrees to work toward providing public health services, for which it has some available grants. Read full sectionThe provision of care in Mali is organized in a pyramid with four levels. At the base there are the health districts (60), divided into health areas that have a community health center (CSCOM) with a dispensary, a maternity center, and a pharmacy warehouse, altogether offering a minimum package of activities (MPA). The professional team at the CSCOM is often managed by a nurse. In 2010, about 900 of the 1,030 health areas had a CSCOM. The health area, and thus the CSCOM, is run by a community health association (ASACO). There were 954 ASACOs in 2010. The ASACO signs a contract with the government of Mali, which agrees to work toward providing public health services, for which it has some available grants. However, it manages the CSCOM staff and the operating budget. CSCOM has the status of a non-profit private institution, and thus the system is “community” based. Roughly 87% of the population of Mali lives less than 15 km from a CSCOM. The CSCOMs account for 56% of all consultations, versus 20% for the entirely public entities (BCG 2010). The first referral takes place at the referral health center (CSRef), which is basically a district hospital. There is a CSRef in every health district. The CSRef has a more sophisticated technical support center and more highly skilled staff than at the CSCM level. The CSRef treats the cases that are referred from the CSCOMs. At the CSRef level, which has public status, there are about 25 private facilities (BCG 2010). At the third level (second referral), there are seven (7) public hospitals (EPH) located in the regional capitals. On the private side there are approximately 70 clinics at this level of the pyramid. (BCG 2010). At the top there are four level-three referring EPHs, two of which are for general medicine, while the other two are for specialized medicine. MutuellesService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The provision of care in Mali is organized in a pyramid with four levels. At the base there are the health districts (60), divided into health areas that have a community health center (CSCOM) with a dispensary, a maternity center, and a pharmacy warehouse, altogether offering a minimum package of activities (MPA). The professional team at the CSCOM is often managed by a nurse. In 2010, about 900 of the 1,030 health areas had a CSCOM. The health area, and thus the CSCOM, is run by a community health association (ASACO). There were 954 ASACOs in 2010. The ASACO signs a contract with the government of Mali, which agrees to work toward providing public health services, for which it has some available grants. However, it manages the CSCOM staff and the operating budget. CSCOM has the status of a non-profit private institution, and thus the system is “community” based. Roughly 87% of the population of Mali lives less than 15 km from a CSCOM. The CSCOMs account for 56% of all consultations, versus 20% for the entirely public entities (BCG 2010). The first referral takes place at the referral health center (CSRef), which is basically a district hospital. There is a CSRef in every health district. The CSRef has a more sophisticated technical support center and more highly skilled staff than at the CSCM level. The CSRef treats the cases that are referred from the CSCOMs. At the CSRef level, which has public status, there are about 25 private facilities (BCG 2010). At the third level (second referral), there are seven (7) public hospitals (EPH) located in the regional capitals. On the private side there are approximately 70 clinics at this level of the pyramid. (BCG 2010). At the top there are four level-three referring EPHs, two of which are for general medicine, while the other two are for specialized medicine. |
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| Chile: National Health Fund (FONASA) |
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In 1985, two modalities of health service provision were established for FONASA beneficiaries. Under the Institutional Modality (IM), FONASA beneficiaries can access the public system in order to use public hospitals. Financial coverage under this modality is dependent upon the income of the beneficiary. Under the Free Election Modality (FEM), FONASA beneficiaries can opt to use private health service providers that have entered into agreements with FONASA. Financial coverage under this modality depends on the category to which the health service provider is subscribed. Generally, FEM copayments are larger than IM copayments. Read full sectionIn 1985, two modalities of health service provision were established for FONASA beneficiaries. Under the Institutional Modality (IM), FONASA beneficiaries can access the public system in order to use public hospitals. Financial coverage under this modality is dependent upon the income of the beneficiary. Under the Free Election Modality (FEM), FONASA beneficiaries can opt to use private health service providers that have entered into agreements with FONASA. Financial coverage under this modality depends on the category to which the health service provider is subscribed. Generally, FEM copayments are larger than IM copayments. Chile’s service delivery system is composed of 26 autonomous health authorities responsible for hospital care. Primary health care was decentralized down to the level of the municipality. In Chile, 80% of hospital beds are public. FONASA is required to purchase most of its health services from public institutions, although it does provide a subsidy to its enrollees wishing to purchase services from private providers. Public health care providers must sell most of their services to FONASA and have strict guidelines on the type and number of services they can make available to private patients or ISAPRE beneficiaries. FONASA categories B, C, and D can elect to receive care outside of the public system for a higher co-payment. Category A enrollees must receive services from the public provider system. Of all the AUGE procedures carried out, 86% are conducted at the primary health level. Meanwhile, of the AUGE procedures for FONASA beneficiaries performed in the private sector, 90% correspond to dialysis treatment. Whenever there is a risk of falling behind on the guarantees, services must be purchased from elsewhere. For example, in the case of cancer a public hospital will normally purchase services from another public hospital. In the case of cataracts, however, a public hospital will normally purchase services from the private sector. The AUGE plan has changed the manner in which health service delivery is viewed. In the past, supply determined how many cataract interventions were performed based on the internal capacity of the institution. But now, with certain services explicitly guaranteed, the health system has to detect the prevalence of cataracts and determine how to best reorganize resources in order to satisfy demand. Chile has also instituted a free telephone line that responds to inquiries regarding a number of different health situations. It is staffed by a team that has the ability to provide medical advice and set up consultations. This service has led to a significant reduction in emergency room visits, as problems that are deemed non-urgent can be resolved through primary care personnel. Finally, it is worth noting that ISAPREs are not allowed to provide health services directly to their enrollees. They must rely on horizontal networks of health care providers and hospitals for the delivery of services. National Health Fund (FONASA)Service delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: In 1985, two modalities of health service provision were established for FONASA beneficiaries. Under the Institutional Modality (IM), FONASA beneficiaries can access the public system in order to use public hospitals. Financial coverage under this modality is dependent upon the income of the beneficiary. Under the Free Election Modality (FEM), FONASA beneficiaries can opt to use private health service providers that have entered into agreements with FONASA. Financial coverage under this modality depends on the category to which the health service provider is subscribed. Generally, FEM copayments are larger than IM copayments. Chile’s service delivery system is composed of 26 autonomous health authorities responsible for hospital care. Primary health care was decentralized down to the level of the municipality. In Chile, 80% of hospital beds are public. FONASA is required to purchase most of its health services from public institutions, although it does provide a subsidy to its enrollees wishing to purchase services from private providers. Public health care providers must sell most of their services to FONASA and have strict guidelines on the type and number of services they can make available to private patients or ISAPRE beneficiaries. FONASA categories B, C, and D can elect to receive care outside of the public system for a higher co-payment. Category A enrollees must receive services from the public provider system. Of all the AUGE procedures carried out, 86% are conducted at the primary health level. Meanwhile, of the AUGE procedures for FONASA beneficiaries performed in the private sector, 90% correspond to dialysis treatment. Whenever there is a risk of falling behind on the guarantees, services must be purchased from elsewhere. For example, in the case of cancer a public hospital will normally purchase services from another public hospital. In the case of cataracts, however, a public hospital will normally purchase services from the private sector. The AUGE plan has changed the manner in which health service delivery is viewed. In the past, supply determined how many cataract interventions were performed based on the internal capacity of the institution. But now, with certain services explicitly guaranteed, the health system has to detect the prevalence of cataracts and determine how to best reorganize resources in order to satisfy demand. Chile has also instituted a free telephone line that responds to inquiries regarding a number of different health situations. It is staffed by a team that has the ability to provide medical advice and set up consultations. This service has led to a significant reduction in emergency room visits, as problems that are deemed non-urgent can be resolved through primary care personnel. Finally, it is worth noting that ISAPREs are not allowed to provide health services directly to their enrollees. They must rely on horizontal networks of health care providers and hospitals for the delivery of services. |
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| Korea, Rep.: National Health Insurance Program |
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Health care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided for-profit by the private sectorKorean patients with health insurance are able to go to any doctor or medical institution that they choose without being denied, except specialized general hospitals. If a patient wants to go to a secondary or tertiary care hospital, they must present a referral slip issued by the original medical practitioner. The exceptions to this include: childbirth, emergency medical care, dental care, rehabilitation, family medicine, and hemophiliac disease. Higher co-payments are requested for those patients without a referral letter. Read full sectionHealth care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided for-profit by the private sectorKorean patients with health insurance are able to go to any doctor or medical institution that they choose without being denied, except specialized general hospitals. If a patient wants to go to a secondary or tertiary care hospital, they must present a referral slip issued by the original medical practitioner. The exceptions to this include: childbirth, emergency medical care, dental care, rehabilitation, family medicine, and hemophiliac disease. Higher co-payments are requested for those patients without a referral letter. The Medical Law stipulates that only authorized and licensed healthcare professionals can provide health services. The Ministry of Health and Welfare (MoHW) licenses only doctors, dentists, nurses, oriental medical doctors, and midwives, while nurse’s aides, acupuncturists, and massage therapists are licensed as quasi-medical professionals. As of 2007, there were 91,400 physicians, 23,114 dentists, 16,663 oriental medical doctors, 57,176 pharmacists, 8,587 midwives, and 235,687 nurses. However, wide disparities exist between urban and rural areas; about 90% of physicians are concentrated in urban areas. Health care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided (de facto for-profit) by the private sector. The 10% of the public service system are composed of community public health centers known as Bogeunso, the National Medical Center, and provincial hospitals. There has been less of a push from the public sector to formulate policy alternatives to the private sector–dominated delivery system. National Health Insurance ProgramService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: Health care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided for-profit by the private sectorKorean patients with health insurance are able to go to any doctor or medical institution that they choose without being denied, except specialized general hospitals. If a patient wants to go to a secondary or tertiary care hospital, they must present a referral slip issued by the original medical practitioner. The exceptions to this include: childbirth, emergency medical care, dental care, rehabilitation, family medicine, and hemophiliac disease. Higher co-payments are requested for those patients without a referral letter. The Medical Law stipulates that only authorized and licensed healthcare professionals can provide health services. The Ministry of Health and Welfare (MoHW) licenses only doctors, dentists, nurses, oriental medical doctors, and midwives, while nurse’s aides, acupuncturists, and massage therapists are licensed as quasi-medical professionals. As of 2007, there were 91,400 physicians, 23,114 dentists, 16,663 oriental medical doctors, 57,176 pharmacists, 8,587 midwives, and 235,687 nurses. However, wide disparities exist between urban and rural areas; about 90% of physicians are concentrated in urban areas. Health care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided (de facto for-profit) by the private sector. The 10% of the public service system are composed of community public health centers known as Bogeunso, the National Medical Center, and provincial hospitals. There has been less of a push from the public sector to formulate policy alternatives to the private sector–dominated delivery system. |
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| Ghana: National Health Insurance Scheme (NHIS) |
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1368 | 966 |
In order to provide the basic package of services, NHIS covers both public and private health care providers at all levels of the health system, subject to their accreditation by the NHIA. As of December 2009, 966 private, 1,368 public and 163 CHAG providers were enrolled in NHIS. Read full sectionIn order to provide the basic package of services, NHIS covers both public and private health care providers at all levels of the health system, subject to their accreditation by the NHIA. As of December 2009, 966 private, 1,368 public and 163 CHAG providers were enrolled in NHIS. At present all public facilities have been given a provisional accreditation and 800 private providers (many of them pharmacies and ‘chemical shops’) have been accredited by the NHIA. National Health Insurance Regulations (LI 1809, Regulation 19 (1)) state that the first point of attendance for accessing health care under the NHIS should be a primary healthcare facility. This includes CHPS, health centers, district hospitals, polyclinics, quasi public hospitals, private hospitals, clinics and maternity homes. Where the only facility is a Regional Hospital, it will also be considered a primary healthcare facility. In emergencies, any accredited healthcare facility may be utilized. National Health Insurance Scheme (NHIS)Service delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 1368
Number of non-state providers: 966 In order to provide the basic package of services, NHIS covers both public and private health care providers at all levels of the health system, subject to their accreditation by the NHIA. As of December 2009, 966 private, 1,368 public and 163 CHAG providers were enrolled in NHIS. At present all public facilities have been given a provisional accreditation and 800 private providers (many of them pharmacies and ‘chemical shops’) have been accredited by the NHIA. National Health Insurance Regulations (LI 1809, Regulation 19 (1)) state that the first point of attendance for accessing health care under the NHIS should be a primary healthcare facility. This includes CHPS, health centers, district hospitals, polyclinics, quasi public hospitals, private hospitals, clinics and maternity homes. Where the only facility is a Regional Hospital, it will also be considered a primary healthcare facility. In emergencies, any accredited healthcare facility may be utilized. |
| Nigeria: National Health Insurance System |
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The National Health Insurance system (NHIS) accredits both service providers and the Health Maintenance Organizations (HMOs) that interface between providers, the NHIS and its beneficiaries. To receive accreditation, health facilities must meet a number of requirements for the physical facility and the personnel, including:
The National Health Insurance system (NHIS) accredits both service providers and the Health Maintenance Organizations (HMOs) that interface between providers, the NHIS and its beneficiaries. To receive accreditation, health facilities must meet a number of requirements for the physical facility and the personnel, including:
In addition, an accreditation fee is required. Currently 61 HMOs have been accredited and registered by NHIS in addition to about 6,000 primary care providers, 1,000 ancillary providers, and over 600 secondary and tertiary providers. Recently the NHIS announced the suspension of accreditation of new HMOs and providers because there is a need to strengthen the scheme and improve quality of healthcare services delivery through reaccreditation. In general, the service delivery system in Nigeria is organized on a tiered basis:
The service delivery system is mixed between private and public providers. The private health care system has grown substantially since the 1980s, to currently provide about 80% of the total health services. This sector, however, is not well regulated or supported. Of all the private facilities in Nigeria, about 50% are for-profit. Despite the large number of service providers, coverage of most key preventative and curative health services is relatively low. There are large disparities in geo-political zones, between rural and urban zones, and with regard to socio-economic status; the poorest fifth of the population are much less likely to receive medical services than their counterparts in the wealthiest 20% of the population. National Health Insurance SystemService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The National Health Insurance system (NHIS) accredits both service providers and the Health Maintenance Organizations (HMOs) that interface between providers, the NHIS and its beneficiaries. To receive accreditation, health facilities must meet a number of requirements for the physical facility and the personnel, including:
In addition, an accreditation fee is required. Currently 61 HMOs have been accredited and registered by NHIS in addition to about 6,000 primary care providers, 1,000 ancillary providers, and over 600 secondary and tertiary providers. Recently the NHIS announced the suspension of accreditation of new HMOs and providers because there is a need to strengthen the scheme and improve quality of healthcare services delivery through reaccreditation. In general, the service delivery system in Nigeria is organized on a tiered basis:
The service delivery system is mixed between private and public providers. The private health care system has grown substantially since the 1980s, to currently provide about 80% of the total health services. This sector, however, is not well regulated or supported. Of all the private facilities in Nigeria, about 50% are for-profit. Despite the large number of service providers, coverage of most key preventative and curative health services is relatively low. There are large disparities in geo-political zones, between rural and urban zones, and with regard to socio-economic status; the poorest fifth of the population are much less likely to receive medical services than their counterparts in the wealthiest 20% of the population. |
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| Brazil: Unified Health System (SUS) |
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Primary care delivery happens through primary care units and primary care teams under the Family Health Program (PSF). Primary care units are run by municipalities and are mostly managed by government-employed clinicians. These units are funded on a per capita basis based on the population size within the catchment area. While patients can use clinics outside of their area, they may be encouraged or referred back to their corresponding primary care unit. Read full sectionPrimary care delivery happens through primary care units and primary care teams under the Family Health Program (PSF). Primary care units are run by municipalities and are mostly managed by government-employed clinicians. These units are funded on a per capita basis based on the population size within the catchment area. While patients can use clinics outside of their area, they may be encouraged or referred back to their corresponding primary care unit. In some municipalities, primary care units are contracted-out through RFP on a winner-take-all basis to NGOs, who receive similar per capita budgets as government health centers but are not subject to civil service rules. They can more easily hire and fire and some are experimenting with pay for performance mechanisms. Service delivery within the Family Health Program (PSF) and the Community Health Agents Program (PACS) is the responsibility of the Municipal Health Secretariat. The PSF is the program through which the government reorganized some of the organization and delivery of publicly financed primary health care (In recent years, the PSF has also covered chronic diseases). In essence, it has turned a passive, facility-based delivery system into a dynamic, outreach model in which family healthcare providers deliver care to households and communities. There is a primary care team responsible for a territory of 800-1,000 families, or up to 4,000 people. The team includes a generalist physician, a nurse, a community health agent, and an odontologist or dental hygienist. The team monitors and evaluates the health situation of the population, provides primary care services, and makes referrals to other levels of the system. The number of PSF teams increased from zero in 1994 to close to 32,000 by 2008. The primary purpose of the PACS is to improve the health and quality of life of the community. PACS utilizes community personnel with no higher education to engage in a wide variety of activities such as registering families, general diagnostics, sanitary health, looking out for critical situations in need of intervention, and overall follow-up with families and patients. The delivery of secondary and tertiary health care services under the SUS is conducted through both public and private providers. Public contracting of private hospitals has a long history in Brazil, where the SUS contracts for private beds. In 1999, 67% of all SUS hospitals were privately owned, 8% were state owned, and 23% were municipally owned. In terms of clinics, 27% were privately owned, 3% were state owned, and 69% were municipally owned. Such ratios make it clear that while the SUS is a publicly funded system, the private sector is responsible for a large proportion of the services provided. The role of the private sector in service delivery appears to be waning slightly. Between 1988 and 2005, public establishments offering hospitalizations grew by 50%, while private establishments offering the same grew by 23%. Public contracting of services with private providers is allowed under MOH guidelines. Managers can complement the supply of services with private providers only when all public health capacity is being used and when the need is proven and justified. Charitable and non-profit organizations, however, are given the status of public sector partners. Furthermore, in order for private entities to be able to provide service to the SUS, they must agree to make available 60% of their capacity to the SUS. These private entities can only serve private users once capacity has been exhausted by SUS patients. Unified Health System (SUS)Service delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: Primary care delivery happens through primary care units and primary care teams under the Family Health Program (PSF). Primary care units are run by municipalities and are mostly managed by government-employed clinicians. These units are funded on a per capita basis based on the population size within the catchment area. While patients can use clinics outside of their area, they may be encouraged or referred back to their corresponding primary care unit. In some municipalities, primary care units are contracted-out through RFP on a winner-take-all basis to NGOs, who receive similar per capita budgets as government health centers but are not subject to civil service rules. They can more easily hire and fire and some are experimenting with pay for performance mechanisms. Service delivery within the Family Health Program (PSF) and the Community Health Agents Program (PACS) is the responsibility of the Municipal Health Secretariat. The PSF is the program through which the government reorganized some of the organization and delivery of publicly financed primary health care (In recent years, the PSF has also covered chronic diseases). In essence, it has turned a passive, facility-based delivery system into a dynamic, outreach model in which family healthcare providers deliver care to households and communities. There is a primary care team responsible for a territory of 800-1,000 families, or up to 4,000 people. The team includes a generalist physician, a nurse, a community health agent, and an odontologist or dental hygienist. The team monitors and evaluates the health situation of the population, provides primary care services, and makes referrals to other levels of the system. The number of PSF teams increased from zero in 1994 to close to 32,000 by 2008. The primary purpose of the PACS is to improve the health and quality of life of the community. PACS utilizes community personnel with no higher education to engage in a wide variety of activities such as registering families, general diagnostics, sanitary health, looking out for critical situations in need of intervention, and overall follow-up with families and patients. The delivery of secondary and tertiary health care services under the SUS is conducted through both public and private providers. Public contracting of private hospitals has a long history in Brazil, where the SUS contracts for private beds. In 1999, 67% of all SUS hospitals were privately owned, 8% were state owned, and 23% were municipally owned. In terms of clinics, 27% were privately owned, 3% were state owned, and 69% were municipally owned. Such ratios make it clear that while the SUS is a publicly funded system, the private sector is responsible for a large proportion of the services provided. The role of the private sector in service delivery appears to be waning slightly. Between 1988 and 2005, public establishments offering hospitalizations grew by 50%, while private establishments offering the same grew by 23%. Public contracting of services with private providers is allowed under MOH guidelines. Managers can complement the supply of services with private providers only when all public health capacity is being used and when the need is proven and justified. Charitable and non-profit organizations, however, are given the status of public sector partners. Furthermore, in order for private entities to be able to provide service to the SUS, they must agree to make available 60% of their capacity to the SUS. These private entities can only serve private users once capacity has been exhausted by SUS patients. |